IV Therapy: Finding The Enemy

To initiate IV access, start by placing the patient’s arm in a dependent position.  Apply a tourniquet around the arm to slow the proximal flow of blood and distend the veins.  Place the tourniquet above the antecubital fossa or approximately 4 to 6 inches (10 to 15 centimeters) above the anticipated site.

Prepare the tourniquet approximately 4 – 6 inches above the antecubital fossa, or the intended site of venipuncture.

To secure the tourniquet, overlap the ends and then stretch them in opposite directions. Next, tuck the top end under the bottom end.   For easy removal later, leave a bit of the tourniquet on the side you started from.  This will allow you to simply pull the tab out from under the band to release the device.  

The tourniquet should be snug, but not too tight as this can injure or bruise the patient’s arm. If the patient has fragile skin or excessive hair, place the tourniquet over the sleeve of the gown to protect the skin and avoid pulling the hair.

Several challenges arise in patients with excessive hair in potential IV sites.  First, visualization of the veins may be difficult.  Second, antiseptic cleanser may not be able to reach the skin where it is needed.  Third, adhesive tape may not stay properly, compromising the security of the IV.  Taping over excessive hair will also cause significant discomfort to your patient.  Remove the hair by clipping it to a shorter length.  Shaving is not recommended as this may cause micro-abrasions in the skin, and allow for microbes to infect the body.

If the patient has fragile skin or a tourniquet is not available, a blood-pressure cuff may be utilized in place of a tourniquet.  Place the cuff on the patient’s upper arm and inflate it to just below the patient’s normal diastolic pressure. Once you inflate it, keep it inflated until after you have inserted the IV catheter.

Caution: A tourniquet is intended to briefly decrease venous blood return to aid with the insertion of the IV catheter into a vein. While it should be applied snugly, it should not be tight enough to impede arterial blood flow. If you are unsure if the tourniquet is too tight, palpate a distal pulse.  If the distal pulse is absent, remove the tourniquet immediately and re-apply it with less force.  Do not leave a tourniquet on for longer than 4 to 6 minutes to avoid nerve injury and blood clot formation.  

When looking for peripheral intravenous (IV) access, begin by looking at the most distal part of the extremity and move proximal.  Look first for veins that are more prominent as they will be easier to puncture.  Just seeing  a bluish line on a person’s arm does not mean the veins will be easy to access.  Palpate the veins to feel their structure.  When you push down on them, the veins should feel a bit spongy and bounce back.  The easiest veins to access are those that are visible in color and raise the skin slightly.  As a beginner, look for the “low hanging fruit first”.  As you get better and better, you will be able to successfully attempt those “hard sticks”.

The cephalic, basilic, and median cubital veins in the hand and forearm are the veins most often used for initiating IV therapy. This is because they are larger, closer to the surface and generally straight.  This makes them easier to puncture, and less likely to rupture than other veins in the hand and arm.

Since large veins in the hand are close to the skin, they are often visible, palpable and straight. This makes them a good choice for peripheral IV installation.

While you may place an IV in the antecubital site, this is generally not a good choice.  Since this is an area of flexion, the risk for kinks and dislodgement is greater.  Forcing the joint to be immobilized to avoid these complications limits the range of motion a patient has, and might interfere with daily living activities.  In addition, if the antecubital veins are damaged, the possibility of using distal sites may be eliminated.  Also, the antecubital vein can be accessed repeatedly for blood sampling.  Therefore, reserve the antecubital for this purpose when possible.

If you are having problems finding a well-dilated vein,  try to gently stroke the extremity below the intended IV site from distal to proximal to “push” blood into the vicinity.  Alternatively, consider placing a warm pack, blanket or towel on the extremity for a couple of minutes to increase dilation.  Avoid rubbing the extremity vigorously or flicking the vein.  This may cause the vein to constrict or damage to the vein may occur.  Consequently, a hematoma may form.

When possible, avoid using veins in an extremity with compromised circulation.  Also avoid installing an IV distal to previous IV sites, sclerosed or hardened veins, bruised areas, and areas where there are valves or bifurcations.  This will increase the risk of extra-venous infiltration.  If the patient has excessive body hair, do not shave the area.  Clip the hair with scissors. as shaving can cause micro-abrasions, increasing the risk for infection.

Once you have found your target, make sure that placing the IV catheter in that location will not interfere with any planned procedures or with the patient’s ability to perform activities of daily living.  It never hurts to evaluate additional possibilities as well, should you need to re-attempt installation.

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